#labordelivery

So, I’ve been working labor and delivery at my little hospital for almost 6 months now, and I’m officially off of my graduate residency orientation and working night shifts. Still a baby nurse, but no longer a heavily supervised and assisted nurse. And for the most part, I do still absolutely love what I am doing and the actual work of helping parents become parents. However, I’m definitely bumping into something of a rub, which is simply this: I cannot care more about how someone’s birth goes than they do. I mean, I /can/, but I don’t know if that attitude has longevity in a career niche that already faces a lot of compassion burnout.

It isn’t uncommon, working on other floors of the hospital, to encounter patients who really just don’t care about their own health and well being. No amount of teaching or trying on your part can impart onto them that their current habits and lifestyle choices aren’t just bad for them, they’re killing them, rate dependent on how bad the choices are. Even in nursing school, I saw so much of this, but when you’re on a general medical-surgical floor, it comes in a variety of packages: the diabetic whose sugar levels aren’t controlled but who still sends their adult kids out to buy them Ho-ho’s after having their foot amputated for diabetes-related neuropathy, the drug addict who leaves AMA after having his abscess lanced but not treated because he isn’t allowed to smoke next to the pure oxygen valve, and so forth. Compassion fatigue is a real thing, and it’s hard to not look at the patients willfully killing themselves despite all the information and caring you show them, and /not/ begin to draw judgments on who deserves your intervention and who you just give up on. That’s not ever how I wanted to practice nursing, but I can surely see how many become a little more callous, a little less naive, to the possible detriment of their patients.

But this takes on a whole new look on a labor and delivery and postpartum floor, especially in one such as my hospital that 1) doesn’t have a NICU, so by virtue cannot care for anything above a medium risk patient (we’ll provide emergent care but as soon as that patient or baby is stable, we transport them to one of our sister hospitals) and 2) over half the patients are on Medicaid.

I went into LD with a background already as a doula, working across the strange gap that is class and privilege. I volunteered as a doula and worked with very young moms, unsupported moms, moms on Medicaid using public services, moms who were incarcerated even. On the flip side, I charged for my services clients who wanted doulas and were from a completely different subset of our community but I think you can already guess their label: middle to upper-class, suburban, largely white women. My moms who I volunteered for were just as motivated to have good births for their children, and all of them had educated themselves enough to know they wanted a doula present at their birth for whatever reason. Leaving aside the fact that as a whole society, we as a country are woefully undereducated about how women’s bodies, and so therefore 9/10 of the mothers I helped as a doula were completely blindsided by all that goes into childbirth in our healthcare system, there was still a very clear difference between my moms of privilege versus those I volunteered for. The mothers I volunteered with were often the moms I needed to educate most, because by virtue of their position, they had less time and money to invest in learning everything about giving birth before it was upon them. Rarely, in any of the clients I saw as a doula who I helped educate, was lack of knowledge due to lack of interest; they knew next to nothing about what to expect mostly because they lacked access resources (no WiFi for Internet or YouTube access, shared phones with partners, no money to buy birthing/what to expect books, no transportation to even get to a library, limited access in virtually every aspect you can imagine, period). And these moms often also had little choice in who they saw as their providers. And let’s be clear on this point too: few providers at this junction have the time to educate their patients properly either, on top of the fact that many women are far too intimidated to ask a doctor questions about their own bodies (ie what are you doing with your hand up there, why is it even in there, what is that body part called).

Taking and knowing all of the above information, which I saw as a doula doing pre-birth interviews, means that what I see in my labor and delivery department is so painfully frustrating for so many many reasons. The moms I saw as a doula all knew enough to have asked for a doula; in my 6 months at my hospital, I have seen maybe 3 doulas total, and all for women who could pay for that privilege. Again, more than half of my patients are on Medicaid, so we are talking at the very least about women who are within a certain range of the poverty line. The lack of education regarding what is happening to their bodies is astounding, and the advantage our physicians and nurses take of this lack of knowledge is sometimes sickening. As a singular example, not once, in the 6 months of labors I have assisted with, has a practitioner explained what he or she was doing before they broke a bag of water (the amniotic sac that surrounds and cushions the baby throughout pregnancy). The doctor waltzes in, hopefully says hi to the patient, gloves up, lays the patient back for a cervical check meaning up the vagina goes their hand, they stretch their free hand out to me with unspoken expectation for the amnihook (this little plastic tool that looks like a crochet hook), they insert and manipulate that and pop goes the water sack surrounding the baby. At no point in this process was there a discussion of what was coming with the mom, or permission asked, or any knowledge imparted (save what I explain before the physician arrives). The whole process takes maybe two minutes, sometimes only one (and I know this because it is my job to chart when a doctor comes into the room and when he/she leaves). And once that doctor leaves, my patients look to me and ask, “What just happened?”

My background already means that I know, from study and interest and my own pregnancy, that there is NO documented benefit to breaking a patient’s water before a certain stage of labor. Even breaking it after a particular juncture bears little to no concrete evidence for expedited labor, or less chance of a c-section (which, ostensibly, we are all trying to avoid for our patients but in reality don’t seem to care one way or the other about). Breaking the water DOES increase the chance of infection, especially with multiple cervical checks (more hands up in that vagina) as labor progresses. Some hospitals put a time limit on how long a patient can labor with a broken water before they are signed up for a section (this is less a practice at my hospital, but it warrants mentioning all the same). There is also some argument, though nothing definitive so take it with a grain of salt, that breaking that bag of waters with a mal-positioned baby (a baby who isn’t quite lined up yet with the birth canal in an optimal position) increases the chance for a c-section, because that baby ain’t moving far from where it came down when the balloon popped. Amniotic fluid allows a little more flexibility of movement to get a baby into more optimal position through movement of the mom, but with it gone, that is more challenging (and that aspect of breaking water /has/ been studied, it’s just whether that is more likely to lead to a section that is in question).

This is my singular example of a very easy, yet still fairly invasive (when you stop and think about what it entails) procedure during labor that gives little to no benefit to patient or baby but, above all else, is /not/ discussed ahead of time with the patient. It is simply a part of the birth process and is therefore done. There are a lot of things that are just “done” in healthcare that I may or may not disagree with, but I liken this to a doctor coming in and cutting into a part of you at the bedside with no introduction, explanation, or discussion. The fact is, there are a lot of people who wouldn’t bat an eye even at that because we have a system of unquestioning trust for our doctors, but I think still there are more people now who would at least say, “Um... what are you doing?” at some juncture. Especially because no part of a cervical check or AROM (artificial rupture of membranes, or what the physician breaking the water gets documented as) comes with pain medication. It is uncomfortable, even painful, depending on the lie of the cervix, length of the procedure (how long it takes to get the hook inserted through the cervical opening and puncture the bag), etc.

This post has gotten far longer than I meant for it to be and has definitely waded deeper into the reeds than I intended, but ultimately my point is this: it is hard for me, so very hard, to watch interventions like an AROM be performed without the explicit knowledge or consent of my patients. But the reality is, many of them would likely not care one way or the other if they were told their water was going to be broken. If you asked them before doing the procedure, many would defer to their physician’s choice because they do not know what it entails, what it means in the short term, or what it could mean in the longer-term. And remember, this is my one example of one procedure out of many we perform in LD, but it is reflective for what much of the practice of labor and delivery looks like. We tell our patients little, we expect them to go along with our and the physician decisions, and the best time to educate honestly isn’t at the juncture where they are in pain, contracting, trying to get that baby into the world. It isn’t even at the juncture where they walk through the LD doors. It’s the months prior to that moment, when they’re seeing their doctor or preparing for birth.

Leading me back to the problem I originally started writing about, which started with me thinking about epidurals this morning. It used to be, probably up to 15 years ago and possibly even less time ago than that, that patients were not allowed to receive epidural anesthesia for birth until they reached an arbitrary dilation number (the cervix dilates to 10cm before pushing, it depended on practitioner but I hear a lot of “you needed to be 4-6cm” along when this is talked about). The thinking behind this was that epidurals slowed labor, or stopped it, so you wanted patients to be in full-blown labor before giving them an epidural. And there was a point where you would no longer give one, which I’ve heard said to be the 8cm mark. Of course the issue there, besides the fact that that left a lot of moms who expected pain relief had to wait on it, was that there is no way to tell how fast someone will dilate or at what pace. I, personally, arrived for my first birth already 7cm dilated. It still took 6 more hours to get to 10. A girlfriend of mine recently arrived at hospital 5 hours into her labor at 8cm, which would have meant no epidural for her. My mother wanted an epidural SO BADLY, I cannot tell you how much that point is covered when she reviews her birth experiences with me, with both of her pregnancies; with me, she was too little dilated to keep at the hospital the first 2 times they went, and then she was far too advanced to receive one. My younger brother she was 4cm and he was delivered 45 minutes later (caught by a nurse, no less). Now, today, my girlfriend at 8cm got an epidural. My patients who come in at 2-4 cm, depending on contraction pattern, get their epidurals pretty quickly after they start to feel uncomfortable. And from a pain relief standpoint, I am so about this; I want women to be able to have the births they want, and that usually does not include the pain part. I am perfectly happy to appease them there. But last night, I read an article about how a hospital in I want to say North Carolina lowered their c-section rates from 31% to 26% in 6 months with their only intervention being to move their patients. Change positions every thirty minutes: walk them, squat them, lean them. It’s what we do as doulas to help our moms who don’t want epidurals, and I as a doula encouraged it for as long as my moms felt they could go. And I was thinking about how we could possibly implement this in my hospital, with my moms, and had this immediate sinking realization. There is no way I would be able to convince the moms who come in, who want no part of labor pain or experience, that their and their babies outcomes will be better if they wait longer on an epidural so that they can move more in labor. Not unless we had a rule in place where we kept them from epidurals again, taking away one of the few areas they have voice and the ability to say, “Yes I want this” or “no I don’t” in our current climate. And that is in part because the majority come in not understanding what happens in birth at all (I have had to explain what a vagina was, and countless times what the cervix is which let me at least add that I LOVE teaching women about their bodies, I love being able to do that, but when you’re about to push a baby out does NOT feel like the right time for a general reproductive parts lesson from me, your labor nurse). We don’t educate our pregnant women, we don’t give them the tools they need to care, and then we arrive at how this at all affects me (besides the obvious reason, that I’m clearly affected enough to write a long rambling narrative on my day off while I’m supposed to be relaxing in the bathtub -my bathwater has long since gone cold, and the book I have to read for pleasure remains unopened beside me).

The truth is, I cannot care more about what happens in my patients’ labors than they care. I can’t care more about whether you have a c-section than you do, or whether you breastfeed or whether you tear or really anything. I /do/ care, I care so much, but I can’t be more invested in your outcome than you, my patient, are. And I feel set up to be burned out, or to be the labor nurse who just goes through the motions, because of how under educated my patients are. I know some of them are like those med-surg patients, who it wouldn’t matter if you led the horse to water or practically drowned them in it, they would still choose to do their thing away from the water and that’s just that. But I don’t think that’s most of my patients. So many of these mothers are just women who want what is best for their babies above all else. I want them to also want what is best for them, for their bodies and their reproductive health, and it isn’t something I can impart along with everything else in a 12 hour labor. I will come away burnt to a crisp if I continue to care more about whether a mom has her baby vaginally or by c-section when she doesn’t care. At the same time, how can she care when she doesn’t know that she should care?